In the PD REHAB trial, combined therapy wasn't associated with any clinically meaningful improvements in activities of daily living (ADL) or quality of life (QoL) compared with a control group that didn't get therapy, Carl Clarke, MD, of the Sandwell and West Birmingham Hospitals National Health Service Trust in Birmingham in England, and colleagues reported online in JAMA Neurology.

"This evidence does not support the use of low-dose, patient-centered, goal-directed physiotherapy, and occupational therapy in patients in the early stages of PD," they wrote. "Future research should explore the development and testing of more structured and intensive physical and occupational therapy programs in patients with all stages of PD."

In an accompanying editorial, however, J. Eric Ahlskog, PhD, MD, of the Mayo Clinic in Rochester, Minn., noted that the study results "should be interpreted with attention to the study details." He warned that the study didn't focus on therapy for targeted problems, and that physical or occupational therapy should focus on specific problems that are likely to benefit.

Ahlskog also added that these findings shouldn't have an impact on the benefits of aerobic exercise in Parkinson's, which "substantial, albeit indirect, evidence" from "a variety of investigations" has shown that it has a neuroprotective effect.

In the open-label, parallel-group, controlled efficacy trial, 762 patients with mild-to-moderate PD were recruited from 38 sites across the U.K. between October 2009 and June 2012. The mean age was 70 years, and 67% of patients had H&Y stage 2 disease or less and a median NEADL total score of 54.

A total of 381 study participants were randomized to receive physical and occupational therapy, while a control group with the same number of patients was randomized to receive no therapy.

Over an 8-week period, patients in the treatment group received a mean of 4 hours of physical therapy and occupational therapy combined. Physiotherapy was used to address issues of gait, posture, balance, physical conditioning, and transfers. Occupational therapy addressed transfers, dressing and grooming, sleep and fatigue, indoor mobility, household tasks, and issues related to the patient's environment.

Although most patients had mild disease, all of them reported ADL problems at baseline, producing a mean baseline NEADL score of 51 that may have led to a floor effect, the researchers cautioned.

But a subgroup analysis showed that even in patients with the most severe baseline NEADL scores, there was still no significant response to physical and occupational therapy.

These therapies are more commonly used in patients in the later stages of PD (H&Y stage ≥3), when they begin to experience falls, the researchers noted. By comparison, patients in the PD REHAB trial were in the early stages of disease (H&Y stage <3 at randomization).

"It is possible that such mild-to-moderate disease may not respond to the therapies, whereas more severe disease may respond, although this remains to be established," they wrote. "As a consequence, the results of the PD REHAB trial can only be generalized to patients with mild to moderate disease."

Ahlskog noted that patients were excluded from the trial if their clinicians believed they needed physical and/or occupational therapy.

It makes sense that patients with PD-related problems such as gait freezing, imbalance/fall risk, or immobilized limbs would benefit from routine PT, he said. Similarly, patients with a shortened stride or reduced arm swing would benefit from PT strategies to increase attenuated movements.

"Current physical/occupational therapy referrals for those with PD should be for specific problems that are likely to benefit," he wrote. "Such circumscribed problems were not the focus of this investigation."

Finally, none of the therapies included aerobic exercise, which may slow the progression of PD: "Physical therapy practices should begin to incorporate facilitation of ongoing aerobic exercise and fitness," he wrote.

The PD REHAB Trial was supported by the UK National Institute for Health Research Health Technology Assessment Programme.

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